Maggot Debridement Therapy in the Treatment

of Complex Diabetic Wounds

Michelle L. Marineau PhD, APRN; Mark T. Herrington APRN;
Karen M. Swenor APRN; and Lawrence J. Eron MD, FACP, FIDSA
Abstract

the skin. Approximately 40-50 maggots were carefully inserted into

the wound bed with a sterile Q-tip and gauze moistened with saline
was applied on top of the maggots. The mesh, supplied by Monarch
Labs, was then glued to the DuoDERM with rubber cement, forming a mesh cage, which conned the maggots to the wound bed
(Figure 1). A bulky dressing was applied over the wound.
The patients and family members were advised not to disturb the
dressing and warned that they would see increased drainage. The
patients were then scheduled for follow-up appointments 48 hours
later if they were out-patients, or treated in their hospital room 48
hours later if they were in-patients. After 48 hours the wound mesh
was removed, and the maggots were then extracted from the wound
with wall suction (Figure 1). If the wound was not completely debrided, maggots were reinserted and the wound covered again with
mesh. This cycle continued until full debridement was attained.
Twelve of the 23 patients who began MDT as in-patients, were
continued on MDT as out-patients. The other eleven patients were
all begun on MDT as out-patients. All of the patients had diabetes
in addition to multiple other co-morbidities, with 13 of the patients
having a hemoglobin A1c > 10 (range 6.1 to 17.3, mean of 10.2).
These diabetic patients had the most challenging wounds for debridement often times due to compromised vascularity, not amenable to
sharp debridement. Five patients were on chronic hemodialysis with
end-stage renal disease (ESRD). Eleven of the 23 patients wounds
had extended to the bone with underlying osteomyelitis
Successful therapy was dened as full-debridement of the wound
bed with enhanced granulation tissue formation with or without full
closure of the wound. Often, MDT was followed by the application
of negative-pressure wound dressings once satisfactory debridement
was obtained. This encouraged the rapid formation of granulation
tissue. Contraindications to MDT were open wounds in large body
cavities and wounds in close proximity to large blood vessels. The
team avoided MDT in patients allergic to eggs, soybeans or y
larvae. Coagulopathy was not a contra-indication but such patients
were monitored closely since increased bleeding is common during
therapy.

The growth and aging of the population of Hawaii with a high incidence of diabetes mandates a need for more effective strategies to
manage the healing of complicated wounds. Maggot debridement
therapy (MDT) is one alternative utilized with successful results.
Observations have indicated that maggots have the ability to debride wound beds, provide anti-microbial activity and also stimulate
wound healing in diabetic patients. None of the patients refused
MDT due to aversion of this treatment modality and the majority of
patients had minimal discomfort. In 17 of 23 patients with multiple
co-morbidities, the treatment of their complex diabetic wounds by
MDT resulted in improvement or cure. Maggot debridement therapy
is an effective treatment of diabetic wounds.

Introduction
Patients with diabetes have difculty healing wounds. This is
especially true in the elderly whose numbers are increasing, resulting in rising cost for the delivery of health care. The annual cost
to manage these wounds exceeds 20 billion dollars,1 with a loss of
over two million work days.2 The diabetic foot ulcer in particular is
more difcult to treat, costing between $7,000 to $10,000 per ulcer.
Many of these ulcers may ultimately require amputation of a limb,
where the cost may be as high as $65,000 per person.3
There are numerous dressings to choose from, with costly new
products coming to the market on a monthly basis, all claiming to
improve outcomes. Maggot Debridement Therapy (MDT) has been
infrequently used in the last 60 years due to improved dressings,
new surgical techniques, and the surge of new antibiotics to treat
non-healing wounds when they become infected.4 Medical-grade
maggots became commercially available in 2004,5 and today there is
a resurgence of interest in MDT with 12 laboratories in 20 countries
dispensing them at low cost.6 They are approved for debridement
of wounds with necrotic tissue, including pressure ulcers, venous
ulcers, neuropathic foot ulcers, and non-healing traumatic or postsurgical wounds.7 A prospective, randomized study8 of patients with
wounds comparing MDT to conventional therapy demonstrated
the efcacy of MDT in debriding wounds, but there was no difference in the rate of healing. However, uncontrolled diabetics were
excluded from the study. Furthermore, as there are no healthcare
facilities using this treatment modality in the State of Hawaii, the
authors felt that a report of a case series of patients treated locally
in Hawaii with MDT, might be an impetus for further study and
usage in this State.

Results
The team began MDT in the fall of 2009 in a diabetic patient with
a non-healing right hallux amputation. The wound would not close
due to multiple co-morbidities (end-stage renal disease, diabetes,
and heart disease). A negative- pressure wound dressing led to
necrosis of his toes due to insufcient arterial ow. He adamantly
refused a below-the-knee amputation. Previous studies9,10 have
demonstrated fewer amputations using MDT when compared to
conventional therapy. So, MDT was employed to assist in wound
debridement and closure of the wound. Subtotal granulation occurred
within one month, although devitalized bone still extruded from the
wound. After three further months of MDT, complete debridement
of exposed bone was obtained (Figure 1).

Methods
Patients with diabetic wounds were evaluated for MDT and written
consent for treatment was obtained. The maggots (Lucilia sericata)
were obtained from Monarch Labs in Long Beach, California for
$98.00 per vial plus shipping. Each vial contained 250-500 maggots
that were viable long enough for two MDT treatments. The skin
was prepped with CavilonNo Sting barrier lm wipes and then
Mastisol was applied to increase the adherence of DuoDERM to

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Figure 1
Over the past nine months the team has treated 23 diabetic patients
with MDT. Clinical outcomes are displayed in Table 1. In 17 of 23
patients, successful outcomes were achieved by MDT. These 17
patients exhibited complete debridement with the formation of robust
granulation tissue within their wounds. In fact, 6 of these patients
formed granulation tissue over exposed tendons, avoiding tendon
excision. While MDT may not completely close patients wounds,
partial closure of wounds was obtained in all of the successfully
treated patients. For example, one patient with severe lymphedema
had been treated since 2006 without any perceptible closure of his
venous stasis ulcers. In 10 days, 75% closure of his ulcers was
achieved by MDT. Two of the successfully treated patients required
a skin graft to achieve full closure, and several others demonstrated
further closure of their wounds with negative-pressure dressings.
One patient with a large eschar over a below-knee amputation site
demonstrated successful debridement of the eschar by MDT but
initially did not exhibit granulation in the wound bed. After 30
days, MDT was discontinued and a negative-pressure dressing was
applied. After one week further deterioration of the wound bed was
observed thought to be due to impaired arterial ow to the extremity.
Wet-to-dry dressings were instituted and successful closure of the

wound was obtained. Another remarkable feature observed during

the treatment of diabetic patients with peripheral neuropathy was
the return of normal sensation after several MDT treatments.
Six of 23 patients did not signicantly benet from MDT. Three
patients who had osteomyelitis of the bones of their feet did not
benet from MDT due to narrow openings of their wounds (i.e.,
<1cm). Robust granulation tissue formation induced by MDT led
to closure of their wounds before the maggots were able to reach
the necrotic bone for debridement. In patients that had sufcient
exposure of bone, therapy was successful with an apparent halt of
bony destruction. A fourth patient had a deep venous stasis ulcer
with documented leukocytoplastic vasculitis. The maggots ruptured
a vein in her leg causing bleeding which necessitated early discontinuation of the MDT. She was not on anticoagulants. A fth patient,
severely debilitated from a coronary artery bypass graft, congestive
heart failure, a cerebral vascular accident, and thrombocytopenia,
was anti-coagulated with heparin. The maggots that were placed in
his foot ulcer caused excessive bleeding. In a sixth patient who was
status-post surgical debridement of a wound, excessive inammatory
reaction at the margins of the wound necessitated discontinuation
of MDT. A negative-pressure dressing resulted in enlargement of

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Table 1. Results of MDT

Wound

Co-Morbidities

66

Age
M

Sex

R foot with OM

ESRD, DM, HD, PAD, OB

6.5

Hgb. A1c

60 days

Length of MDT
Successful

Outcomes

78

L foot

CABG, CHF, DM , CVA, OB, CRF

7.7

14 days

Unsuccessful - Excessive bleeding

56

R foot with OM

DM, OB

13.5

10 days

Successful

38

R foot with OM

DM , OB, CHF

11.9

2 days

Unsuccessful -Area closed in one treatment

57

R foot with OM

DA, DM, CVA, HD, S, CRF, CHF

11.9

11 days

Successful

61

R foot with OM

DM, ESRD, HD, CVA, CHF

10.5

15 days

Successful

78

BVSU

DM, LE, OB, COPD, CHF, CRF, HD

6.2

10 days

Successful Three of four ulcers healed

72

R foot with OM

CRF, DM, HD

12.2

2 days

Unsuccessful -Area closed in one treatment

61

R BKA hematoma

DM,HD, CHF, CRF

8.1

30 days

Successful with delayed response

57

R foot

DM, HD, S, ETOH

12.8

10 days

Successful

51

R foot

DM, CRF

15.6

4 days

Successful

60

R foot with OM

DM, HD, OB, PAD

10.6

10 days

Successful

45

L Calf Ulcer

DM, OB, CRF

8.1

1 days

Unsuccessful -Ruptured vein

41

R foot with OM

DM ,CRF, HD

17.3

12 days

Successful

46

L foot

DM, OB, CRF

11.5

4 days

Successful

60

R Calf

DM, OB

10.6

6 days

Unsuccessful due to pyoderma gangrenosum

56

R foot

DM

12.0

14 days

Successful

49

L foot

DM, OB, HD

9.4

10 days

Successful

56

L foot

DM, HD

54

R Hallux with OM

DM

60

L Hallux with OM

58

43

6.2

8 days

Successful

13.6

8 days

Successful

DM, ESRD, Stroke, PD

6.1

4 days

Unsuccessful insufcient opening to dead tissue

L foot with OM

DM, HD, ESRD

6.3

4 days

Successful

L foot

DM, HD, OB, ESRD

6.2

6 days

Successful

OM osteomyelitis; DM diabetes mellitus; HD heart disease; OB obesity; PAD peripheral arterial disease; ETOH ethanol abuse; CHF congestive heart disease; CRF chronic
renal failure; ESRD end stage renal disease; CVA cerebral vascular accident; CABG coronary arterial bypass graft; S smoker; LE lymphedema, VSU venous stasis ulcers, DA
drug addiction, COPD chronic obstructive pulmonary disease, BKA below knee amputation.

the wound, which the team later realized was due to pathology, as
she was then diagnosed as having pyoderma gangrenosum.
In 60% of diabetic patients treated with MDT, erythema developed
in normal skin surrounding the wound. The inammatory reaction
disappeared within 24-48 hours following temporary interruption
of MDT, which was thereafter resumed without a resumption of the
exhuberant inammatory reaction. None of the patients discontinued
MDT due to an aversion of having maggots placed in their wounds.
All of the patients were agreeable to the therapy and most were
enthusiastic about this treatment option. Several of the patients complained of discomfort requiring analgesics. This has been previously
reported in patients treated with MDT compared to conventional
therapy.8 The patients that experienced pain had exposed bone and
described the pain as a dull aching sensation that was adequately
managed with oral analgesics. One patient temporarily interrupted
therapy due to discomfort, but then resumed treatment a short time
later without difculty. Some patients did complain of a creepy
crawling sensation in their wounds. One patient had maggots escape
after getting the dressing wet. A few of the health care professionals
were squeamish about assisting in the application and removal of
the maggots.

Discussion
Wound debridement, originally thought to be a mechanical effect
of the maggots,11 has been shown to be due to three proteolytic
enzyme classes that were identied in the maggot excretions.12
Maggot excretions have an inhibitory effect on both Gram-positive
and Gram-negative bacteria including methicillin-resistant Staphylococcus aureus, methicillin-sensitive S aureus, Escherichia coli,
and Pseudomonas aeruginosa.13 The ammonia excreted by maggots
is believed to alter the pH of the wound, which inhibits bacterial
growth.14 In 2001 a group of investigators examined the viability
of E coli in the gut of the maggot Lucilia sericata and found 67%
of the proximal alimentary canal heavily infected. However, in
the hindgut there was only 18% viable bacteria, demonstrating the
bactericidal effect of maggot gastrointestinal secretions.15
There have been several studies attempting to identify how the
maggots increase granulation in the wound bed. A study conducted
in 2006 demonstrated an increased migration (but not proliferation)
of the broblasts which was attributed to the action of serine and
metallo-proteinases.16 Another study found high levels of gammainterferon and interleuken-10 in the excretions of maggots that were
thought to increase granulation tissue formation.17

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The literature recommends not using maggots in a dry wound bed

since they require a moist wound to survive.4 The team employed
MDT successfully in dry wounds since the maggots create their own
moist environment. It is important to advise patients of increased
drainage from their wounds while receiving MDT since several of
the patients verbalized fear that their condition was worsening when
they observed increased drainage. MDT was a preferred method for
patients who were not operative candidates due to their underlying
vasculopathy. MDT is selective as maggots consume only necrotic
tissue, leaving viable tissue intact. Patients needed reassurance that
their wounds were not worsening when an exuberant inammatory
response surrounded their wounds. This disappeared in the majority
of the patients in 24 to 48 hours, following temporary interruption
of MDT. The patient with pyoderma gangrenosum experienced
continued inammation for 96 hours, which was likely due to pathology.

In 2004, the Food and Drug Administration approved medicalgrade maggots for the treatment of chronic wounds. 7 At least one
randomized trial8 supports its use compared to conventional therapy.
However this trial excluded uncontrolled diabetics. Since many
patients with limb ulcers in Hawaii have uncontrolled diabetes, the
current study focused on this group, where the authors found MDT
to be effective treatment.
Disclosure: The authors report no conicts of interest.
Authors Afliation:
- Kaiser Permanente, Division of Infectious Disease
3288 Moanalua Road Honolulu, HI 96819
Correspondence to:
Michelle L. Marineau PhD APRN; 55-249B Kamehameha Hwy., Laie, HI 96762;
Ph: (808) 432-7793; Fax: (808) 432-7796; Email: michelle.l.marineau@kp.org

Conclusions
Maggots are able to debride diabetic wounds and stimulate wound
healing. This study demonstrates that MDT is an effective strategy
for the treatment of complex, diabetic wounds. Furthermore, the
authors have shown that MDT works in dry, gangrenous wounds
as well. Patient acceptance of, and satisfaction with, MDT was
excellent. The majority of the patients tolerated MDT well with
only a few experiencing pain that was adequately controlled with
oral analgesics.

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